Rectocele repair in obstructed defecation :...

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Rectocele repair in obstructed defecation : randomized comparative

study

BY

MOHAMED FARID MD.TAREK MAHDY MD.

HESHAM A. MONEIM MD. WALEED OMAR MD.

FROM

COLORECTAL SURGERY UNIT, MANSOURA UNIVERSITY

HOSPITAL, MANSOURA, EGYPT

---------------------------------------------------------------------------------- ADRESS FOR CORRESPONDANCE: MOHAMED FARID Professor of general surgery & Head of Colo-Rectal Surgery Unit, Mansoura University Hospital, Mansoura, EGYPT. P.O BOX: 324, MANSOURA, EGYPT. TEL. 050/ 2219403 FAX: 050/ 2267016 E-mail : [email protected]

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ABSTRACT

Purpose: this study was undertaken to evaluate the results of

transperineal repair with or without levator ani repair and transrectal repair

of rectocele as regards both anatomic and symptomatic concerns. Methods:

between December 1998 and December 2000, we performed a prospective

study of 48 female patients with obstructed defecation due to rectocele. All

patients were studied prospectively according to a fixed protocol that

included clinical evaluation, defecography, and manometric studies, which

were performed preoperatively, and 6 months postoperatively. Transperineal

repair was done in 31 patient (15 with levator ani repair) and transrectal

repair in 17 patients. Results: six months postoperatively there was a

significant clinical improvement in all patients except those who underwent

transrectal repair. Postoperative defecography showed decrease of rectocele

size in all patients but significant improvement in rectal evacuation occurred

only in patients with transperineal repair. Postoperative manometric studies

showed a significant decrease in the Urge To Defecate Volume (UTDV) and

Maximum Reflex Volume (MRV) in transperineal approaches. There was a

significant difference between patients who did or did not feel improved by

surgery in the percentage reduction in the volume at which an urge to

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defecate was elicited (UTDV) and the Maximal inhibitory anal Reflex

Volume (MRV) in all surgical approaches. Conclusion: Rectocele repair

improves anorectal function by improving the rectal urge sensitivity. This

study displays the efficacy of transperineal approach with levator ani repair.

Decrease of UTDV, MRV, reduction of rectocele size and complete

evacuation were considered the convenient parameters for the success of

surgery.

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Introduction

Rectocele is a common finding in patients with defecation disorders,

and its role in these disorders remains debated (1,2). Up to 30 percent of

middle aged and elderly adults feel constipated (3). Seventeen percent of

adults, strain excessively at stool and 12 percent use laxative (4). Difficulty in

rectal evacuation is frequently seen in multiparous women. Obstetric

damage and increasing laxity of tissues with increasing age are possible

patho-genetic factors (5,6). Rectocele can give rise to a variety of symptoms,

such as blood loss, pain, pruritis, fecal incontinence, and digital (rectal or

vaginal) assistance to defecate. These symptoms may be caused by damage

to the anterior rectal wall, a nonspecific inflammatory reaction as well as

anatomic and physiological changes in rectal accommodation (7).

In clinical practice, the relationship between anatomic abnormalities and

symptoms is not clear. Rectocele occurs in 20 to 81 percent of both

asymptotic females and patients with constipation (8). Only 23 to 70 percent

of unselected patients with rectocele have symptoms related to difficulty in

defecation (9,10). It is important to identify a rectocele when it is the cause of

obstructive defecation and proper repair of recto-vaginal septum results in

gratifying improvements in constipation problem (11). Symptoms are not

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always alleviated by either vaginal, transperineal or transrectal rectocele

repairs (1,10,12,13,14). It is not known whether failure of surgical repair in these

patients relates to the failure to correct or there are other factors.

The principal aim of our study is to evaluate the results of

transperineal repair with or without levator ani repair and transrectal repair

of rectocele considering the anatomic and symptomatic improvements.

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Patients & Methods

From December 1998 to December 2000. A prospective randomized

study was followed. During this period 60 female patients with obstructed

defecation underwent operation for rectocele. Of those screened, 55 patients

passed the exclusion criteria (slow- transit constipation using radio opaque

markers and abnormal thyroid function) and were fully informed about

transrectal and transperineal repair with or without levator repair. Inclusion

criteria involved rectocele size more than 2 cm that were associated with one

or more of the following symptoms (digital manipulation during defecation,

incomplete evacuation, excessive straining or sexual function disturbances

mainly dysparaunia). Of the 55 patients meeting the inclusion criteria, 48

patients [median age, 42 (range 26 - 61) years] were agreed to randomization

and signed an informed consent. Drawing sealed envelopes containing the

transrectal participants, the transperineal participants and transperineal with

levator repair participants were blinded the randomization. The sample size

was estimated on the basis of the number of patients predicted to present

with obstructive defecation due to rectocele over a predefined recruitment

period of 2 years. All patients were evaluated preoperatively according to a

standardized protocol. This included a detailed questionnaire, with special

reference to defecation frequency, use of laxative, excessive straining,

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digital manipulation during defecation, sensation of incomplete evacuation,

frequency of incontinence, stool consistency, blood loss, dysparaunia and

past history of pelvic or anorectal surgery. All patients had been studied

preoperatively with digital assessment, rigid proctoscope and defecography

was performed as described by Ginai (15). Defecographic findings included

rectocele size and contrast evacuation of the rectocele (grade 0: no

evacuation, grade 1,2,3,4: evacuation was poor, moderate, subtotal and total)

(16). Rectal evacuation was evaluated using the same grading of rectocele.

Perineal descent and anorectal angle were also evaluated (17,18). Anorectal

manometry using perfusion catheter systems (Synectics, Stockholm,

Sweden) (19,20) was done for all patients with the evaluation of maximum

anal resting pressure (MRP), maximum anal squeezing pressure (MSP),

rectal sensitivity threshold volume (STV), urge to defecate volume (UTDV),

maximum tolerable volume (MTV), anal inhibitory reflex threshold (RTV),

maximum reflex volume (MRV) and functional anal canal length (cm).

Transperineal repair was done for thirty- one patients (15 with levator ani

repair) and transrectal for seventeen patients (2,12,21,22). Patients were followed

up routinely for one to two months after surgery. Functional results were

evaluated after six months (by examiners blinded the type of operative

treatment for each patient) by anal manometry, defecography and

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questionnaire reflecting the symptomatic results. Outcome was considered

(improved) if the main symptoms disappeared and not improved if it

persisted. Statistical analysis was performed using nonparametric tests for

comparisons. For qualitative data, chi- square or fisher’s exact probability

tests (two samples, unpaired) or Mc Nemar test (two samples, paired) was

used. For quantitative data Wilcoxon`s signed rank test (two samples,

paired) with correction for ties was used. To investigate the relationship

between change in rectocele size dimension and symptoms or the type of

surgery the Mann Whitney test with correction for ties was used. Two-sided

values ? 0.05 were considered significant.

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Results

As shown in table (1), 75 percent of patients were complaining of

constipation and straining during defecation. 79.2 percent of patients

experienced a feeling of incomplete emptying. 75 percent of patients

digitally assisted defecation through vagina and 60.4 percent of patient

experienced dysparaunia. Postoperatively there was a significant

improvement of symptoms in patients with transperineal repair.

As regards the defecographic findings, there was a significant

decrease in the rectocele size in all surgical approaches (table 2) and

significant improvement of rectocele evacuation after transperineal repair on

the contrary in transrectal repair patients (Table 3). Moreover, there was also

a significant improvement in rectal evacuation following transperineal repair

(table 4).

There was significant difference between patients (who did or did not

feel improved by surgery) in the percentage reduction in rectocele size and

evacuation (table 5,6) in all surgical approaches. In table (7) there were

significant changes in the MARP, UTDV and MRV in transperineal

approach with or without levator ani repair but not with transrectal repair.

On the other hand, there was significant difference between patients

(who did or did not feel improved by surgery) in the percentage reduction in

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the volume at which an urge to defecate was elicited (UTDV) and the

maximal inhibitory anal reflex volume (MRV), in all surgical approaches. It

was also noticed that, in the transperineal approach with levator ani repair,

there was significant differences between improved and not improved

patients in the percentage reduction in the MARP (table 8).

It is noted from table (9) that, there was significant improvement in

patients who had transperineal approach with levator ani repair versus the

transrectal repair.

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DISCUSSION

Normal defecation is a complex neuromuscular process that requires the

integration of neuromuscular activity of large bowel, rectum and pelvic

floor muscles, together with the absence of anatomical factors that inhibit

this process (23). A rectocele is a herniation of the anterior rectal wall

through the rectovaginal septum into the vagina (11). The most important

risk factors are a previous hysterectomy, obstetric injuries and the

descending perineum syndrome (5,6). In some patients the rectocele

becomes symptomatic because of defecation disorders (9,10). The patients

have to give manual vaginal or perineal help during defecation (24). Many

authors have recognized that the relationship between impaired defecation

and the presence of a rectocele is a complex one (25, 26). We believe that

rectocele repair produces symptomatic benefits through anatomical

improvement and mechanisms that alter rectoanal evacuation, as it could

be notified from our results that there is significant improvement in

evacuation although the rectocele did not disappear completely.

We consider defecography has an impact on the diagnosis and estimation of

outcome after surgery. Sarles et al (27) advocated that retention of contrast

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medium in the rectocele could be used for selection of patients for rectocele

repair. The present study shows, significant reduction in size of rectocele in

the three surgical approaches, but complete evacuation of rectocele was

significant only in the two-transperineal approaches, probably this could be

explain the significant improvement in symptoms after transperineal

approach specially with levator ani repair rather than patients with

transrectal repair. Concerning manometric studies, we think that changes in

UTDV are a sensible predictor for improvement after surgery. This concept

is reinforced by the idea that continence during the daytime is more

dependent on rectal sensation of urge than on the sphincter pressure. Thus on

looking to the results and considering this view, we can find that

transperineal with levator repair leads to a more significant reduction in

UTDV, in comparison with other approaches a finding probably not

popularized too much by other investigators. Our findings revealed that

postoperative MARP did not differ significantly from preoperative MARP

value except in transperineal with levator repair. Moreover, the latter

observation suggests that contribution of MARP provided by the external

sphincter tonus was decreased substantially by the operation. We suppose

that, this could be related to a better awareness of urge and sphincter control

without the need for a compensatory protective increase in resting pressure.

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Another significant finding is that the MRV required to induce maximum

anal relaxation is decreased after surgery and is more significantly decreased

after transperineal with levator repair rather than transrectal repair. This may

suggest that obstructed defecation by a large rectal volume is positively

influenced by the repair. This is supported by the finding that outlet -

obstructed patients show a significant increase in stool frequency shortly

after operation. This could be due to the combined significantly improved

rectal sensation (UTDV) with a significantly lowered MRV, and this

probably give an impact in patients with obstructed defecation rather than

the effect of rectoanal inhibitory reflex alone. In most studies (22,24,28), there is

a group of patients who do not benefit from operation. In our study, there is

only 13.3% did not improve after transperineal approach with levator ani

repair which is less than the reports in published series. The results of

rectocele surgery are reported to be satisfactory (1,2, 22). In our study, 86.7% of

rectocele patients were improved after transperineal with levator repair in

contrary to 62.5% and 41.2% improvement after transperineal and

transrectal repairs respectively. This satisfactory clinical data combined with

improvement in anorectal manometry and defecographic findings after

transperineal with levator repair could encourage us to perform this kind of

surgery in management of rectocele. From our results it is noted that

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transrectal repair showed a worse outcome. This could be due to its

dependence only on plicating the rectum up to 10 cm. on the contrary of

transperineal with levator repair which gives a firm rectovaginal septum

with better and accurate access to the apex of rectocele

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Conclusions

Rectocele repair improves anorectal function by improving UTDV, MRV,

reduction of rectocele size and improvement of rectal – rectocele evacuation.

Transperineal with levator repair looks to give a satisfactory outcome rather

than transperineal without levator repair or transrectal repair.

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References

(1) Arnold MW, Stewart WR, Aguilar PS.

Rectocele repair. Four years experience.

Dis Colon Rectum (1990); 33: 684-7.

(2) Khubchandani IT, Clancy JR, Rosen L, et al.

Endorectal repair of rectocele revisited.

Br J surgery (1997); 84: 89-91.

(3) Whitehead WG, Drink water D, Cheskin LJ, et al

Constipation in The elderly living at home: definition, prevalence and

relationship to Lifestyle and health status.

JA M Geriatr soc. (1989); 37: 423 - 9

(4)Sonnenberg A, Everhart JE, Brown DM.

The economic cost of constipation. In: Kamm MA. Lennard-Jones JE,

Eds. Constipation. Petersfield, united kindom: Wrightstown Biomedical

publishing, 1994: 19-29.

(5) Sehapayak S.

Transrectal repair of rectocele: an extended armamentarium of

colorectal surgeons. A report of 355 cases.

Dis Colon Rectum (1985); 28:422-33

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(6) SarlesJc, Arnaud A, Selezneff I, et al.

Endorectal repair of rectocele.

Int J colorectal Dis (1989); 4: 167-71.

(7) Bouchacha M, Denis P, Arhan P, et al.

Morphology and rheology of the rectum in patients with chronic

idiomatic Constipation.

Dis Colon Rectum 1989; 32:788-92

(8) Siproudhis L, Dautreme S, Robert A, et al.

Dyschezia and rectocele-a marriage of inconvenience?

Psychological evaluation of the rectocele in a group of 52 women

complaining of difficulty in evacuation.

Dis Colon Rectum 1993;36:1030-6

(9) Yoshioka K, Matsui Y, Yamade O, et al.

Physiological and anatomic assessment of patients with rectocele.

Dis Colon Rectum 1991

(10) Van laarhoven C, Kamm M, Bartram C, et al.

Relationship between anatomic and symptomatic long-Term results

after rectocele repair for impaired defecation.

Dis Colon Rectum 1999; 42:204-10.

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(11) Richardson Ac.

The rectovaginal septum revisited: its relationship to rectocele

repair.

Clin Obstet Gynaecol 1993; 36:976-83.

(12) Sullivan ES, Leaverton GH, Hardwick CE.

Transrectal perineal repair: an adjunct to improved function after

anorectal surgery.


(13) Janssen LW, Van Dijke CF.

Selection criteria for anterior rectal wall repair in symptomatic

rectocele and anterior rectal wall prolapse.


(14) Infantino A, Masin A, Melega E, et al.

Does surgery resolve outlet obstruction from rectocele?

Int j Colorect Dis 1995;10:97-100

(15) Ginai AZ.

Technical report: evacuation proctography (defecography) a new seat

and method of examination.

Clin Radiol. 1990; 42:214-6.

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(16) Kelvin FM, Maglinte DD, Hornback JA,

Pelvic floor prolapse : assessment with evacuation

proctography ( defecography).

Radiology 1992; 184: 547-51.

(17) Halligan S, McGee S, Bartram CI.

Quan Tification of evacuation proctography.


(18) Van Dam JH, Ginai AZ, Gosselink MJ, et al.

Role of Defecography in predicting clinical outcome of rectocele

repair.


(19) HO YH, Goh HS.

Current value of anorectal physiology and biofeedback in clinical

practice.

Asian J surg 1995; 18:244-56.

(20) HO YH, Goh HS.

Anorectal physiological parameters in chronic constipation of

unknown etiology (primary) and of cerebrovascular accidents : a

preliminary report.

Ann Acad Med Singapore 1995; 24:376-8.

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(21) Karlbom U, Graf W, Nilsson S, et al.

Does surgical repair of rectocele improve rectal emptying?

Dis Colon Rectum 1996; 39:1296-1302.

(22) Mellgren A , Anzen B , Nilsson B , et al.

Results of rectocele repair : a prospective study.

Dis colon rectum 1995 ; 38 : 7 – 13.

(23) Kamm MA, Vander Sijp JR, Lennard-Jones JE.

Colorectal and anal motility during defecation.

Lancet 1992; 339:820.

(24) Lucas W , Cornelis F.

Selection criteria for anterior rectal wall repair in symptomatic

rectocele and anterior rectal wall prolapsed.

Dis colon rectum 1994 ; 37 : 1100 – 7 .

(25) Van dam JH , Schouten WR , Ginai AZ . et al .

The impact of anismus on Clinical outcome of Rectocele repair .

Int. J Colorectal Dis 1996; 11: 238 – 42.

(26) Van dam JH , Hop WC and Schouten WR .

Analysis of patients with Poor Outcome of Rectocele repair.

Dis colon rectum 2000 ; 43 : 1556 – 60

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( 27) Sarles JC, Arnaud A, Sicelezneff I, et al.

Endo-rectal repair of rectocele.

Int j colorectal Dis 1989; 4:167-71.

(28) Block IR .

Transrectal repair of rectocele using obliterative sutures.

Dis colon rectum 1986 ; 29 : 707 – 11

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Table (1): Clinical results of rectocele repair.

All Patients

(48)

Transperineal

repair patients

(16)

Transperineal with

levator repair

patients. (15)

Transrectal repair

patients. (17)

Preoperative 75% 81.3% 73.3% 70.6%

Postoperative 33.3% 37.5% 13.3% 47.1% Constipation

P-value .001 .016 .004 .125

Preoperative 79.2% 75% 86.7% 76.5%

Postoperative 35.4% 37.5% 13.3% 52.9% Incomplete

evacuation P-value .002 .031 .001 .89

Preoperative 75% 75% 80% 70.6%

Postoperative 33.3% 37.5% 13.3% 47.1% Digitation

P-value .001 .031 .002 .125

Preoperative 75% 75% 80% 70.6%

Postoperative 29.2% 25% 13.3% 47.1%

Straining

during

defecation P-value .002 .008 .002 .125

Preoperative 60.4% 62.5% 66.3% 52.9%

Postoperative 33.3% 25% 20% 52.9% Sexual

Disorders P-value .001 .031 .016 -

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Table (2): Rectocele size before and after repair.

Preoperative Postoperative

Mean.

(cm) Minim. Maxim.

Mean

(cm) Minim. Maxim.

P-value

All patients.

(48)

3.79

? .819 2.4 5.5

1.23

?1.259 0 4 .001

Transperineal

repair patients.

(16)

3.8

? .983 2.4 5.4

.937

?.750 0 2 .001

Transperineal

with levator

repair patients.

(15)

4.18

? .770 3 5.5

.937

?.736 0 2 .001

Transrectal

repair patients.

(17)

3.45

? .536 2.9 5

2.08

?1.577 0 4 .002

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Table (3): Rectocele evacuation before and after repair.


Poor Moderate Subtotal Complete Poor Moderate Subtotal Complete P-value

All patients.

(48)

1

2.1%

15

31.3%

26

54.2%

6

12.5% 0

7

14.6%

10

20.8%

31

64.6% .001

Transperineal

repair

patients.

(16)

0 4

25%

7

43.8%

5

31.3% 0

1

6.3%

4

25%

11

68.7% .003

Transperineal

with levator

repair

patients.

(15)

1

6.7%

5

33.3%

9

60% 0 0

1

6.7%

1

6.7%

13

86% .001

Transrectal

repair

patients.

(17)

0 6

35.3%

10

58.8%

1

5.9% 0

5

29.4%

5

29.4%

7

41.2% .157

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Table (4): Rectum evacuation before and after repair.


Poor Moderate Subtotal Complete Poor Moderate Subtotal Complete P-value

All patients

(48)

10

20.8%

18

37.5%

20

41.7%

0

0

9

18.8%

5

10.4%

4

8.3%

30

62.5% .001

Transperi-

neal repair

patients.

(16)

2

12.5%

6

37.5%

8

50%

0

0

1

6.2%

3

18.8%

2

12.5%

10

62.5% .005

Transperi-

neal with

levator repair

patients.

(15)

4

26.7%

7

46.6%

4

26.7% 0

2

13.3% 0 0

13

86.7% .001

Transrectal

repair

patients.

(17)

4

23.5%

5

29.4%

8

47.1% 0

6

35.2%

2

11.8%

2

11.8%

7

41.2% .206

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Table (5): Results of postoperative rectocele size in relation to improvement.

Improved Not improved

No Mean Minim Maxim No Mean Minim Maxim

P-value

All patients

(48) 30/48 .423

?.459 0 1.5 18/48

2.483

? .761 1 4 .001

Transperineal

repair patients.

(16) 10/16

.45

?.371 0 1 6/16

1.75

? .418 1 2 .001

Transperineal

with levator

repair patients.

(15)

13/15 .23

?.388 0 1 2/15 2 2 2 .01

Transrectal

repair patients.

(17) 7/17

.742

?.565 0 1.5 10/17

3.02

? .518 2.2 4 .001

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Table (6) Results of postoperative rectocele evacuation in relation to

improvement.

All patients.

(48)

Transperineal

repair.

(16)

Transperineal with

levator repair. (15)

Transrectal

repair.

(17)

Improved

patients

Complete 30 (100 %) 10 (100 %) 13 (100 %) 7 (100 %)

Poor 0 0 0 0

Moderate 7 (38.9 %) 1 (16.7 %) 1 (50 %) 5 (50 %)

Subtotal 10 (55.6 %) 4 (66.7 %) 1 (50 %) 5 (50 %) Not

improved

patients Complete

1 (5.6 %) 1 (16.7 %) 0 0

P-value

.001 .002 .001 .001

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Table (7): anorectal manometric findings before and after rectocele repair.


Mean Mean

P-value

MARP

(mmHg)

87.12

? 13

80.64

? 16.34

.001

UTDV

(ml)

225.41

? 25.76

199.47

? 33.5

.001 All Patients.

(48)

MRV

(ml)

225.83 ? 27.52 194.02

? 33.2

.001

MARP

(mmHg)

87.31

? 13.54

83.12

? 13.76

.035

UTDV

(ml)

223

? 30.74

196.56

? 36.08

.013 Transperineal repair

patients. (16)

MRV

(ml)

220

? 30.73

176.87

? 22.72

.002

MARP

(mmHg)

85

? 13.75

66. 4

? 14.59

.002

UTDV

(ml)

228

? 25.19

176.66

? 23.11

.001 Transperineal

With levator repair

patients. (15) MRV

(ml)

230.66

? 30.25

176.33

? 24.80

.001

MARP

(mmHg)

88.82

? 12.31

90.88 ? 10.64 .249

UTDV

(ml)

224.41

? 22.69

222.35

? 23.59

.350 Transrectal repair

patients. (17)

MRV

(ml)

226

? 22.14

225.35

? 25.37

.258

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Table ( 8 ) : Results of postoperative anorectal manometric findings in relation to improvement of the three surgical repair patients.

Improved Not improved

Mean Mean

P-value

MARP

(mmHg)

75.7

? 15.84

88.88

? 13.99 .014

UTDV

(ml)

179.16

? 19.96

233.33

? 21.96 .001

All patients.

(48)

MRV

(ml)

178

? 22.99

220

? 31.34 .001

MARP

(mmHg)

81.5

? 10.81

85.83

? 18.55 .912

UTDV

(ml)

177.5

? 20.44

228.33

? 34.88 .006

Transperineal repair

patients.

(16)

MRV

(ml)

166

? 8.43

195

? 28.1 .025

MARP

(mmHg)

62.76

? 11.16

90

? 14.14 .032

UTDV

(ml)

170

? 16.2 220 .025

Transperineal with

levator repair patients.

(15)

MRV

(ml)

169.61

? 15.6

220

? 28.78 .026

MARP

(mmHg)

91.42

? 8.99

90.5

? 12.17 .692

UTDV

(ml)

198.57

? 12.14

239

? 11.97 .001

Transrectal repair

patients.

(17) MRV

(ml)

210.71

? 17.89

235

? 25.71 .34

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Table (9): Comparison of three surgical procedures in relation to improvement.

Improved Not improved P-value

Transperineal with or

without levator repair

VS Transrectal

Repair.

23/31 (74.2%)

7/17 (41.2%)

8/31 (25.8 %)

10/17 (58.8 %) .024

Transperineal with

levator repair VS

Transrectal.

13/15 (86.7 %)

7/17 (41.2 %)

2/15 (13.3 %)

10/17 (58.8 %) .008

Transperineal without

levator repair VS

Transrectal.

10/16 (62.5 %)

7/17(41.2 %)

6/16 (37.5 %)

10/17 (58.8 %) .221

Rectocele repair in obstructed defecation :...

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